Forms
Below are links to all of the most recent MUST forms.
Claims
Accident Questionnaire – updated June 2010
This form may be used for injury claims to determine whether some of the costs can be paid with no deductible under the MUST accident benefit.
Claim Form (Medical) – updated November 2010
Use this form to submit a claim to MUST when you have paid a provider up front for medical or preventive services.
Use this form to submit a claim to Caremark when you have paid for a prescription up front.
Foreign Travel Letter (sample)
If you plan to travel outside the U.S., call the Claims Administration office (1-877-714-5556) for guidance on seeking healthcare from foreign providers. They can mail you a letter that explains the requirements.
High Deductible Health Plan RX Claim Form – updated January 2011
For any prescription-drug claims with service dates prior to July 1, 2011, members covered by a High Deductible Health Plans should submit this form.
Long Term Disability (LTD) Claim Form
Use this form to claim long term disability (LTD) benefits.
Travel Reimbursement Form – updated February 2011
Use this form to request reimbursement for eligible, medically necessary out-of-state travel costs. The second page explains eligible expenses and exclusions.
Enrollment
Basic Plan Acknowledgment Form (Updated April 2011).
Participants enrolling in the MUST Basic plan must sign this affidavit acknowledging that they understand the Basic plan's limitations.
Change Form (updated April 2011).
For reporting name, address, or marital-status changes; terminating coverage; changing active/retiree status. Must be submitted to clerk or HR/payroll person rather than directly to MUST.
Declaration of Domestic Partner Form (Updated April 2010).
Must be notarized and submitted to MUST to establish eligibility for a common-law spouse or adult partner.
Employee Benefit Election Form (Updated April 2011).
Used for making changes in plan elections during the annual Open Enrollment Period. Do not use this form to add or drop dependents; use the Change Form instead.
Employee Termination Form (Updated January 2012).
Use this form to terminate coverage for employees/trustees. (To terminate a dependent’s coverage, use the Change Form.)
Enrollment Form (Updated April 2011).
Used for enrolling new participants and their dependents in health, dental, and/or vision coverage, and to designate beneficiaries for the basic life insurance included with the MUST medical benefit.
Group Health Statement Form (Updated April 2010).
These forms are used for participants in new groups, or for late enrollees in existing groups.
High Deductible Health Plan Acknowledgment Form (Updated April 2011).
Participants who have elected to enroll in the MUST High Deductible Health Plan will be asked to sign this affidavit acknowledging that they understand related limitations.
Life Insurance Enrollment and Beneficiary Form (Updated April 2010).
The Option 1 portion of the form is required for all participants in groups that offer employer-paid life insurance. The Option 2 portion of the form is used only for participants who elect employee-paid life insurance. Beneficiaries for Option 1 and Option 2 coverage are also designated or changed on this form.
Multiple Coverage Inquiry Form [also known as Coordination of Benefits Form]. (Updated May 2011).
This form is completed annually and is used to inform MUST of any other health-benefit coverage that you or your dependents may have.
Life & Long-Term Disability
Life Insurance Enrollment and Beneficiary Form
The Option 1 portion of the form is required for all participants in groups that offer employer-paid life insurance. The Option 2 portion of the form is used only for participants who elect employee-paid life insurance. Beneficiaries for Option 1 and Option 2 coverage are also designated or changed on this form.
Long Term Disability (LTD) Claim Form
Use this form to claim long term disability (LTD) benefits.
Medical History Statement (Standard Life Insurance)
Use this form for life insurance late enrollees and for participants who wish to apply for life insurance amounts above the guaranteed-issue amount.
Other Forms
Authorization to Release Information (HIPAA) – updated September 2010
This form allows participants age 18 and older to allow claims information to be released to one or more designated persons.
COBRA Continuation Rights Notice
This notice is mailed to participants upon initial enrollment describing their right to continue coverage under COBRA if they lose eligibility for group coverage.
Coordination of Benefits Form [listed in Enrollment section as Multiple Coverage Inquiry Form]. (Updated May 2011).
This form is completed annually and is used to inform MUST of any other health-benefit coverage that you or your dependents may have.
District Quote Data (for MUST representatives only) – updated February 2011
This document is used internally for groups who are not currently insured through MUST and are seeking a quote.
HSA Payroll Deduction Authorization Form
Enrollees in the HSA-qualified Consumer Driven Health Plan may provide this form to his/her employer to authorize payroll deductions to fund a Health Savings Account.
HIPAA Notice
This notice is provided to newly enrolled participants to describe the privacy protections provided under HIPAA laws.
Women’s Health and Cancer Rights Notice
This notice is provided annually to participants to discuss certain benefits that are guaranteed under HIPAA laws.